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Evaluation & Management (E&M) 1
The Physicians’ Current Procedural Terminology – 4th Edition (CPT-4) book includes codes for billing Evaluation and Management (E&M) procedures. It is important that providers use the current version of the CPT-4 and report E&M code definitions carefully.
General Information The following paragraphs include general information about E&M
procedures.
Levels of Care Within each category and subcategory of E&M service, there are three to five levels of care available for billing purposes. These levels of care are not interchangeable among the different categories and subcategories of service. The components used to describe and define the various levels of care are listed in the “Evaluation and Management” section of the CPT-4 book.
Unlisted E&M Services CPT-4 codes 99429 (unlisted preventive medicine service) and 99499 (unlisted evaluation and management service) require an approved Treatment Authorization Request (TAR) in order for these codes to be reimbursed.
Providers should include the following documentation when requesting the TAR:
· An adequate definition or description of the nature, extent and need for the procedure or service
· The time, effort and equipment necessary (if appropriate) to provide the service
Modifiers Modifiers used to describe circumstances that modify a listed E&M code are listed with their descriptors in the Modifiers: Approved List and Modifiers Used With Procedure Codes sections of the appropriate Part 2 manual.
Psychotherapy Services Refer to the Psychiatry section in the appropriate Part 2 manual for information about billing E&M services in conjunction with psychotherapy services.
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Evaluation & Management (E&M) 1
Pregnancy-Related Refer to the Pregnancy: Early Care and Diagnostic Services section of
Services: this manual for additional information.
New Patient A new patient is one who has not received any professional services
Reimbursement from the provider within the past three years. If a new patient visit has been paid, any subsequent claim for a new patient service by the same provider, for the same recipient received within three years will be paid at the level of the comparable established patient procedure.
RAD Reductions The payment resulting from this change in the level of care will be made with a Remittance Advice Details (RAD) message defining the reduction as being in accordance with the service limit set for the procedure. These codes are listed in the Remittance Advice Details (RAD) Codes and Messages: 001 – 9999 sections in the Part 1 manual. Providers who consider the service appropriate and the reduction inappropriate should submit a Claims Inquiry Form (CIF).
Established Patient An established patient is one who has received professional services
Reimbursement from the provider within the past three years.
Providers On Call If a provider is on call or covering for another provider, any service rendered must be classified as it would have been by the provider who is not available.
E&M Services The following CPT-4 codes for E&M services are separately
Separately Reimbursable reimbursable if billed by the same provider, for the same recipient and same date of service, and if the required documentation is included in the Remarks field (Box 80)/Additional Claim Information field (Box 19) of the claim or on an attachment included with the claim.
· New patient, office or other outpatient visit (99201 – 99205) and new or established patient, office or other outpatient consultation (99241 – 99245)
Claims for codes 99241 – 99245 must document the following:
- Another provider requested the patient consultation;
- Consultation was regarding a separate problem than that of the earlier initial patient visit; and
- Medical necessity
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· New or established patient, subsequent hospital care
(99231 – 99233) and new or established patient, initial inpatient consultation (99251 – 99255)
Code combinations 99231 – 99233 and 99251 – 99255 may be reimbursed when:
- Two different physicians provide inpatient services to the same recipient on the same date with the same group provider number. Documentation must be submitted with the claim to medically justify two services on the same day.
- One physician provides inpatient services to a recipient twice on the same date of service. Documentation must be submitted with the claim to medically justify two services on the same day.
Frequency Restrictions The frequency restriction for CPT-4 codes 99211 – 99214 may be exceeded with medical justification. Providers must submit the medical justification with the original claim when established E&M visits exceed six in 90 days. Providers must document that the patient’s acute or chronic condition requires frequent visits in order to monitor their condition with the goal of decreasing hospitalizations.
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Dispensing of Hormonal Refer to the Family Planning section in the appropriate Part 2 manual
Contraceptives for information regarding E&M services and dispensing of hormonal contraceptives.
Prolonged Prolonged services include outpatient services (CPT-4 codes
E&M Services 99354 and 99355) and inpatient services (CPT-4 codes 99356 and 99357). Reimbursement for these codes requires a minimum of 30 minutes face-to-face contact or unit/floor time beyond the typical time of the visit to be reported. A prolonged service of less than 30 minutes is included in the original visit and should not be reported.
Outpatient Services To report prolonged outpatient E&M services, CPT-4 code 99354
CPT-4 Code 99354 (prolonged evaluation and management or psychotherapy service(s) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour) must be billed in conjunction with
one of the following E&M codes:
CPT-4 Code /Description
99201 – 9920599212 – 99215 / Office or other outpatient visit
99241 – 99245 / Office or other outpatient consultation
99324 – 99328
99334 – 99337 / Domiciliary, rest home, or custodial care visit
99341 – 99345
99347 – 99350 /
Home visit
90809, 90815/ Outpatient psychotherapy with
E&M component
CPT-4 Code 99355 To report additional prolonged outpatient E&M services, CPT-4 code
99355 (prolonged evaluation and management or psychotherapy service(s) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes)
must be billed in conjunction with code 99354.
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Pregnancy Care: Billing When billing any medically necessary service during pregnancy or the postpartum period, include a pregnancy diagnosis code on all claims. Claims submitted without a pregnancy diagnosis code may be denied.
Billing Calculations CPT-4 codes 99354 and 99355 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged outpatient services, take the total face-to-face time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged outpatient E&M services.
Time of E&MVisit Code
Not Included / First Hour / Each Additional
30 Minutes
Less than 30
minutes / Not reported / Not reported
30 – 74 minutes / 99354 / Not reported
75 – 104 minutes / 99354 / 99355
105 – 134 minutes / 99354 / 99355 (quantity of 2)
135 – 164 minutes / 99354 / 99355 (quantity of 3)
165 – 194 minutes / 99354 / 99355 (quantity of 4)
Inpatient Services To report prolonged inpatient E&M services, CPT-4 codes 99356
CPT-4 Code 99356 (inpatient setting; first hour) must be billed in conjunction with one of the following E&M service codes:
CPT-4 Code /Description
99221 – 9922399231 – 99233 / Initial hospital care and subsequent hospital care
99251 – 99255 /
Inpatient consultation
99304 – 99310 / Nursing facility services90822, 90829
/ Inpatient psychotherapy with E&M component
CPT-4 Code 99357 To report prolonged inpatient E&M services, CPT-4 codes 99357
(each additional 30 minutes) must be billed in conjunction with code 99356.
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Billing Calculations CPT-4 codes 99356 and 99357 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged inpatient services, take the total unit/floor time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged inpatient E&M services.
Time of E&Mvisit code
not included / First hour / Each additional
30 minutes
Less than 30
minutes / Not reported / Not reported
30 – 74 minutes / 99356 / Not reported
75 – 104 minutes / 99356 / 99357
105 – 134 minutes / 99356 / 99357 (quantity of 2)
135 – 164 minutes / 99356 / 99357 (quantity of 3)
165 – 194 minutes / 99356 / 99357 (quantity of 4)
Emergency Department Claims for emergency department E&M services must be
Services accompanied by an appropriate diagnosis code reflecting the need for the level of E&M services rendered. Inappropriate upcoding is subject to audit.
No distinction is made between new and established patients in the emergency department. Providers must use CPT-4 codes
99281 – 99285 when billing for emergency department services, whether the patient is new or established.
If a recipient visits the emergency department more than once on the same date of service, the provider should use the recipient’s records from the first visit instead of completing a new evaluation. Claims for E&M services rendered more than once in the emergency department by the same provider, for the same recipient and date of service are reimbursable only if they contain medical justification or an indication from the provider that the recipient came to the emergency department more than once in the same day.
Note: Evaluation and Management (E&M) CPT-4 codes
99281 – 99285 are physician service codes and under most circumstances, only physicians may submit claims for these codes. The treating physician and the emergency department services may not submit separate claims using these codes for the same recipient and date of service.
E&M codes 99284 and 99285 are not reimbursable together or more than once to the same provider, for the same recipient and date of service. Instead, providers should use code 99283 to bill for second and subsequent recipient visits on the same date of service.
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E&M: Place of Service/ The CPT-4 codes listed below are restricted to the following
Facility Type Codes facility type/Place of Service codes:
CPT-4 Code /Description
/ Facility TypeUB-04 /
Place ofService CodeCMS-1500
99201 – 99215 / Office Services / 13, 71, 72, 73, 74, 75, 76, 79, 83 / 11, 22, 24, 25, 53, 65, 71, 7299221 – 99233, 99238, 99239 / Hospital Services / 11, 12 / 21, 25
99221 – 99223,
99231 – 99233,
99238, 99239,
99241 – 99245,
99251 – 99255, / Subacute Care**
99241 – 99245 / Office Consultation / 13, 14, 24, 33, 34, 44, 54, 64, 71, 72, 73, 74, 75, 76, 79, 83, 89 / 11, 12, 22, 23, 24, 25, 53, 55, 62, 65, 71, 81, 99
99251 – 99255 / Initial Inpatient Consultation / 11, 12, 25, 26, 27, 65, 71, 73, 74, 75, 76, 86, 89 / 21, 31, 32, 53, 54, 99
99281 – 99285 / Emergency Department Services / 14* / 23
99291 – 99292 / Critical Care Services / 11, 12, 13, 14* / 21, 22, 23, 41, 42
99341 – 99350 / Home Services / 14, 24, 33, 34, 44, 54, 64 / 12, 55, 99
99460, 99462 / Newborn Care / 11, 12 / 21
99477 / Neonate Intensive E&M / 13, 14, 24, 34, 44, 54 or 64 / 21
* Facility type “14” must be billed in conjunction with admit type “1”
** Specify the appropriate Place of Service and use modifier U2.
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Refer to the CMS-1500 Completion or UB-04 Completion – Outpatient Services section of the appropriate Part 2 manual for facility type/Place of Service codes and descriptions. Refer to the end of these sections to see the correspondence between local and national codes.
Claims for services rendered in an inappropriate facility type/Place of Service will be denied with RAD code 062, “The facility type/Place of Service is not acceptable for this procedure.”
Routine or Standing Services billed to Medi-Cal that are the result of routine or standing
Orders – Hospitals and orders for admission to a hospital or Nursing Facility Level B (NF-B)
Nursing Facilities are not reimbursable when applied indiscriminately to all patients. All
Level B (NF-B) patient orders, including standing orders for particular types of cases, must be specific to the patient and must represent necessary medical care for the diagnosis or treatment of a particular condition. Claims for routine orders will be subject to audit for medical necessity and will be denied if not justified by the facts relating to the case or if in excess of current patient needs.
The use of routine or standing orders is discouraged by the American College of Surgeons, the California Medical Association, the California Association of Hospitals and Health Systems, the Joint Commission on Accreditation of Healthcare Organizations and the American Medical Association.
Board and Care California Code of Regulations, Title 22, Section 51145 defines
Facility Services and “home” as any place of residence of a recipient other than a hospital,
Home Visit Codes Nursing Facility Level A (NF-A) or Nursing Facility Level B (NF-B) where the recipient is a registered inpatient.
Since board and care facilities can be considered “home” for Medi-Cal patients, home visit CPT-4 codes 99341 – 99350 may be used to bill Medi-Cal for visits to patients in these facilities. Procedure codes 99304 – 99316 or 99334 – 99336, used for visits to board and care facilities, are not acceptable and may lead to claim denial. For services rendered in a board and care facility, use the “home” facility type code “33” on the UB-04 or Place of Service code “12” on the CMS-1500 for proper reimbursement.
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